Use or abuse? Health plans erect burdens to imaging
Insurers cite costs while doctors decry delay, denial and deterrent to procedures that might improve outcomes
From the April ACP Observer, copyright © 2007 by the American College of Physicians.
By Bonnie Darves
As the costs of high-tech imaging studies such as CT, PET, MRI and nuclear medicine threaten to eclipse spending on prescription drugs, insurers are moving almost en masse to implement tighter ordering restrictions. But while the restrictions may achieve a reduction in unnecessary test orders, they are also likely to add to internists' already considerable administrative burden.
"The key concern of internists is that this is another hurdle to go over—and we'll have to train someone to go through the steps, which in our practice means we'll need another [full-time equivalent] to handle those [authorizations]," said Robert Monteiro, MD, a New Bern, N.C., general internist and partner in Eastern Carolina Internal Medicine, a 40-internist group. "That's the logistic part, but the sentiment part is that we're fed up with having someone second guess our medical and diagnostic decisions."
Dr. Monteiro, who said his staff spends several hours a month evaluating imaging utilization and appropriateness (there's a 64-slice CT scanner in-house) and seeking radiologist input as warranted, questions the need for outside interference in his ordering decisions. Many of his patients will be affected by the newly implemented prior authorization program launched by Blue Cross and Blue Shield of North Carolina, he said, which has approximately 3.4 million members.
The BCBS of North Carolina program is one of several started in 2005 and 2006, and dozens more are set to roll out in 2007 throughout the country. Armed with evidence that at least 10%, and possibly up to 30%, of imaging tests are either unnecessary or ordered too soon, the plans are requiring either prior authorization or prior notification for big-ticket tests.
Dr. Monteiro does not quibble with the insurer's rationale for trying to reduce unnecessary testing—he serves as the internal medicine representative to BCBS of North Carolina's imaging advisory panel. Nor does he disagree with the guidelines the insurer, through vendor American Imaging Management (AIM), is using as a basis for approving or denying tests. But the potential ramifications for patient care concern him.
"It's what I call the three 'Ds'—the delay, denial and deterrent effect on patient care," he said. While the insurer claims that 70% are approved up front, it's the hassle factor of dealing with appeals and possible denials for the other 30% that he worries about.
Unnecessary testing
For the most part, internists do order the right tests, but there is inappropriate utilization in imaging, just as there is in any diagnostic area, in part because of knowledge deficits on the part of ordering clinicians, said Joseph Tashjian, MD, FACR, president of St. Paul Radiology in St. Paul, Minn.
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"About 10% to 15% of any medical tests ordered probably are not indicated, aren't helpful or aren't correct—and that becomes costly to the insurer. But that's not particular to imaging." —Joseph Tashjian, MD, FACR |
"About 10% to 15% of any medical tests ordered probably are not indicated, aren't helpful or aren't correct—and that becomes costly to the insurer. But that's not particular to imaging," he said. The issue, he observed, is that the cost of an MRI done too soon or unnecessarily is, compared to a blood test, very expensive.
For example, studies show that ordering a lumbar MRI for a patient with recent-onset low-back pain but no neurological, bladder or bowel symptoms has little clinical utility, as does performing a brain CT on a patient with a migraine exacerbation who has a long history of such headaches. Yet it's not uncommon for such studies to be ordered for those indications, radiologists report.
For example, data from Illinois-based American Imaging Management (AIM), whose authorization and notification programs encompass 22 million health plan members, show that 14% of advanced imaging tests ordered by internists in 2005 were withdrawn, redirected (to another test type) or denied. AIM claims that about one-third of such tests performed are unnecessary. In addition, the variation in imaging use from one market to another—from 63 MRIs per 1,000 in Oregon to 84 per 1,000 in Texas, according to AIM 2004 data—likely supports insurers' contention that some ordering is inappropriate.
In another example, a recent analysis by HealthLeaders Research of Nashville, Tenn., attributed 10 cents of every dollar being spent by health plans to high-tech imaging. The Minnesota Council of Health Plans, for example, reported a 12% increase in the number of CT scans of the chest, head, pelvis and abdomen from 2004 to 2005—for a total associated cost of $188.8 million and an increase of $20 million.
Health plans hope that requiring preauthorization or prior notification—which requires physicians to notify the insurer that they're ordering the test but doesn't necessarily stop the order or deny payment for it—will identify outlier providers or inappropriately ordered tests.
"It's a way to control costs by keeping track of doctors who order studies that they [insurers] think are not indicated, and then go back and talk to those doctors," said Dr. Tashjian, to determine whether the issue is a knowledge deficit.
Tufts Health Plan in Massachusetts, which instituted its radiology management program in 2005 using National Imaging Associates, implemented prior authorization to address both costs and to ensure that its members don't unnecessarily undergo repeat diagnostic exams, said Allen Hinkle, MD, the plan's chief medical officer. Tufts' clinical coverage criteria, he said, focus outpatient, non-emergent use of four imaging tests (PET, CT, MRI and nuclear cardiology) that are high-cost, have increasing utilization or are at high risk for inappropriate use.
Practice burden difficult to assess
Most prior authorization programs are structured to enable Web or automated telephone authorization on the initial request, and vendors such as AIM claim that the vast majority of orders are authorized within a few minutes. When denials occur, appeals typically are handled first by a nurse or nurse practitioner, and if authorization still isn't granted, then the further appeal is usually handled by a doctor. Prior notification is more straightforward, but either process takes time, and how plans deal with appeals can vary substantially, according to Christopher G. Ullrich MD FACR, a Charlotte NC neuroradiologist who chairs the Managed Care Committee of the American College of Radiology.
"All of these systems add administrative overhead without any reward for the PCP. The plans as a rule don't provide any reimbursement to jump through the hoops," he said. "The other issue is that some plans handle appeals better than others, and there's a lot of variation [in programs] even within a single market."
Dr. Ullrich also cited concerns about test scheduling-that preauthorization delays may require internists' offices to schedule imaging tests after the patient leaves rather than on the spot, creating more work for staff.
Upside sometimes gets lost
On the plus side, Drs. Ullrich and Tashjian said, the majority of plans are incorporating ACR and ACC guidelines when making authorizations, redirecting tests or issuing denials. But how consistently and correctly those guidelines are used, and how often they're updated, could be an issue. "Most [plans or vendors] are using evidence-based information, most of which comes from the American College of Radiology—but sometimes their information isn't complete and some [guidelines] are further developed," than the ones being used by imaging management firms, Dr. Tashjian said.
Minnesota-based HealthPartners, an integrated system with 640,000 members and more than 10,000 physicians, is taking the prior-notification approach in 2007 because it has seen its high-tech imaging utilization skyrocket, said Pat Courneya, MD, medical director for delivery systems. Overall, CT, MRI, PET and nuclear cardiology costs increased 21% from 2003 to 2004 alone, and accounted for 73% of the increase in total radiology costs. Shoulder MRI procedures per 1,000 members increased nearly 70% from 2001 to 2005, and knee MRI procedures 46%.
"That put it on the radar screen for us, but as we looked into it more we saw this [prior notification] as an opportunity to not only get a hold of the cost issue but also to address the significant variation we saw," he said. In February, HealthPartners implemented prior notification, but will soon have many providers using a more sophisticated decision support tool that can be used at the point of care.
The more important issue is that imaging is mostly being used for sound clinical reasons, said Dr. Tashjian. Imaging studies can provide diagnostic clarification on medical issues that previously required multiple tests or invasive approaches.
"Five years ago patients with abdominal pain didn't get a CT [scan] because we didn't know what it could do—and we used to think that surgeons had to do 20% of appendix [removal] surgeries unnecessarily" to rule out appendicitis. With CT, the three most common causes of pelvic pain, kidney stones, appendicitis and diverticulitis, "can be separated out very well," he said.
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"Ordering has increased, but even the management companies concede that the growth is from advancing diagnostic capabilities." —Robert Monteiro, MD |
Likewise, performing CT angiography of the coronary artery vessels on a patient complaining of chest pain can shorten a workup, and if the findings are negative, might help prevent unnecessary cardiac catheterization, Dr. Monteiro added.
"Ordering has increased, but even the management companies concede that the growth is from advancing diagnostic capabilities," he said. "These are tools for making more accurate and timely diagnoses and avoiding more invasive procedures—and they make for better patient care."
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